活体共聚焦显微镜对角膜移植后排斥反应的观察

目的 应用活体共聚焦显微镜(CMTF)观察角膜移植术后排斥反应。 方法 对穿透角膜移植患者术后定期行CMTF检查。 结果 通过连续共聚焦扫描及焦点分析,得到角膜X、Y轴和Z轴多层精确的、可重复的图像及时间记录四维显示。角膜移植术后角膜可出现多种反应,如角膜上皮反应、基质反应。角膜移植排斥反应主要表现为移植片周围大量圆形细胞浸润、大的异常上皮细胞、基质水肿、基质细胞变为成纤维细胞及细胞排列紊乱。 结论 应用CMTF可直接观测活体角膜各层细胞形态、结构、病理转归及角膜移植免疫排斥的早期反应,以及反应过程的发展,为较早地诊断角膜移植排斥反应提供依据。这是裂隙灯检查所不及的。     

Corneal transplant allograft reactions in unilateral, double corneal transplants

In support of the idea that the HLA system plays a major role in corneal graft rejection, we report these two unique cases. Both had two penetrating grafts in the same eye. One was a regular graft and the second a patch graft to repair a perforation in the initial one. In the first case, the original graft had an allograft reaction and the patch graft remained unaffected. In the second case, an allograft reaction to the patch graft developed while the regular graft remained completely clear. Both grafts in the two cases cleared following medical therapy. The fact that in these two cases rejection reactions involved one transplant only, even though the other graft was subject to the same conditions, implies that the difference in the antigenicity of the two grafts is an important factor in the chain of events leading to rejection.     

共聚焦显微镜对角膜移植术后内皮型免疫排斥反应观察

目的 应用激光共聚焦显微镜(Confocal LaserScaning Microscope,CLSM)观察角膜移植术后内皮型免疫排斥反应的特征及抗排斥治疗后的转归.方法 应用CLSM对16例角膜移植术后内皮型免疫排斥反应的病例,分别在抗排斥治疗前、治疗3～7d和1月后,对其病灶的特定位点进行检查,分析角膜上皮细胞、基质细胞、内皮细胞及免疫细胞的数量及形态学变化.结果 (1)16例患者中,8例可见典型的内皮排斥线,CLSM下:内皮排斥线是由体积较小反光明亮的炎症细胞和体积较大边界不清的异常内皮细胞构成.排斥线经过的区域上皮细胞体积增大,上皮基底层大量树突状Langerhans细胞,基质层水肿增厚,呈网格状改变.内皮细胞体积增大,边界模糊,六边形结构消失,可见多核细胞.基质水肿较重的病例,内皮层面见大量强反光团,内皮细胞无法成像.排斥线以上角膜植片相对透明的部分则各层细胞排列基本规则,内皮面少量免疫细胞附着.另8例表现为植片弥漫水肿混浊,CLSM下表现与内皮排斥线经过区域类同.(2)药物治疗3～7d后,12例患者明显好转.CLSM下见上皮基底层下树突状Langerhans细胞明显减少;基质细胞核清晰可见;内皮细胞恢复六边形结构,密度增加,其表面免疫细胞数量减少.4例患者基质层水肿减轻,中深基质层细胞有变性纤维化现象,内皮细胞层强反光团明显减少,但内皮细胞仍不能清晰成像.此4例患者用药1月后基底膜下仍有局限性树突Langerhans细胞聚集,中深基质层变性纤维化,内皮细胞排列不规则,有变圆或拉长现象.结论 应用CLSM可在细胞学水平对角膜移植术后内皮型免疫排斥反应的过程与转归进行活体的动态观察,对指导抗排斥治疗,有效提高角膜移植排斥反应的诊治水平,具有重要的临床意义.

Abstract：

Objective To demonstrate the features and the outcomes after treatment of endothelial rejection in human corneal allograft rejection by in vivo confocal microscopy. Methods Sixteen patients with endothelium rejection ofallogratt after penetrating keratoplasty were examined by confocal microscopy, to analyze the quantity and morphological changes of corneal epithelial cells, stroma cells, endothelium cells and immune cells before treatment and 3-7days and 1 month after treatment. Results Among the 16 patients, typically endothelial rejection line were seen in 8 cases, another 8 cases' keratic precipitates was diffusely scattered.Confocal microscope images revealed that the endothelial rejection lines were formed by cellular aggregate of small inflammatory cells and damaged larger endothelial cells with pyknotic highly reflective nuclei. With the progression of endothelial endothelia line, epithelium cells were large in size and lose distinct boundaries, numerous Langerhans cells (LCs) were seen in the basement epithelial cell region, keratocytes were altered in appearance with increased visibility of the cytoplasm, damaged endothelial cells decreased in number, increased in size with loss of normal polygonal shape and sticked by highly reflective immune cells which scattered or gathered. In the severely edematous area, the endothelial cells were not visualized with confocal microscopy.After 3 or 7 days of treatment, 12 cases were cured. Confocal microscopy examination revealed that the density of LCs reduced gradually and normal keratocytes were detected, the endothelial cells restored to hexagon structure and the density of immune cells decreased. Endothelial cells of 4 cases still were not visualized with confocai microscopy because of the degeneration fibrosis of deep stromal layer. LCs in the basement epithelial cell region still could be found after I month of treatment, and their endothelial cells appeared elongated or rounded with loss of their normal cell junctions. Conclusions In vivo confocal microscopy can provide us with detailed histopathology proofs and appear dynamically the transformation after treatment of endothelial rejection at cell level. It plays an important role in improving the diagnostic level and directing anti-rejection medication in our clinical practicing works.     

角膜移植排斥反应的共焦显微镜研究

目的：探讨角膜移植术后免疫排斥反应的共焦显微镜特征,在细胞水平为该症的基础和临床研究提供活体、三维与实时的科学依据。方法：应用NIDEK公司提供的共焦显微镜,对11例（11眼）发生角膜移植免疫排斥反应的患眼角膜在不同时期行三维实时扫描成像,并用计算机作定性与定量分析。结果：角膜移植免疫排斥反应的共焦显微镜呈现如下特征：①上皮排斥线是由较小的炎症细胞与受损的较大的上皮细胞混合形成的结构;②上皮下浸润表现为体积较小、折射率高的炎症细胞的聚集,上皮下神经纤维水肿呈串珠状改变,浅基层细胞水肿;③基质排斥反应可见角膜基质细胞水肿,胞体变形,数量减少,并见炎症细胞浸润,后者于缝线周围较明显;④内皮排斥线则是由较小的明亮的炎症细胞与核固缩胞体形态异常的内皮细胞混合而成,随着内皮排斥线的发展,内皮 细胞数量减少,体积变大呈伪足状;⑤以上排斥反应均见新生血管长入植片,并与血管壁可见游动的炎症细胞。结论：应用共焦显微镜可在活体上为角膜移植术后免疫排斥反应提供早期诊断与鉴别诊断的科学依据,并在细胞水平对排斥反应的触发与转归进行活体的动态观察。     

Confocal microscopy in lattice corneal dystrophy

· Background: The purpose of the study was to assess the appearance of lattice corneal dystrophy by means of white-light confocal microscopy. · Methods: Two consecutive patients with lattice corneal dystrophy were prospectively examined. In vivo white-light tandem-scanning confocal microscopy was performed in the right eye of the first patient. Her left eye had undergone penetrating keratoplasty 4 years earlier. Histologic findings of the corneal button were compared with confocal microscopic findings of the right eye. The other patient was monocular and confocal microscopy was performed only in the non-seeing eye. · Results: In both patients, linear and branching structures with changing reflectivity and poorly demarcated margins were visualized in the stroma. The linear structures measured approximately 40–80 μm in width. · Conclusion: Lattice corneal dystrophy presents characteristic linear images on confocal microscopy and should not be misdiagnosed as fungal hyphae in cases of corneal infection. Received: 8 July 1998 Revised version received: 6 November 1998 Accepted: 1 December 1998     

联合自-异体穿透性角膜移植减少排斥反应研究

目的：观察联合自－异体穿透性角膜移植术后植片排斥反应的发生率和疗效。方法：对25例角膜病灶靠近边缘的患者,采用周边部新月形自体植片及中央部异体植片作穿透性移植术,另以植床靠边的旁中央穿透性移植术28例为对照组,比较其术后排斥反应的发生率和角膜散光。结果：两组植片的上皮排斥反应发生率分别为8．0％和32．1％,实质层和内皮排斥反应为28．0％及64．3％,角膜散光为3．82D和6．82D。结论：联合自－异体穿透性角膜移植术可降低术后植片排斥反应发生率及减少术后角膜散光。     

Preliminary findings in corneal allograft rejection in patients with keratoconus

PURPOSE: Classically, corneal allograft rejection is thought to be a T(H)1-mediated phenomenon. However, T(H)2-mediated allograft rejection has been reported in other transplanted organ systems, including the heart and kidney. We previously reported a form of T(H)2-mediated corneal allograft rejection in a murine model with a T(H)2 immune bias. In this study we sought to determine if there was any evidence for this form of corneal allograft rejection in humans. DESIGN: Experimental study with an interventional case series. METHODS: The clinical records of all keratoconus patients undergoing penetrating keratoplasty at the University of Texas, Southwestern Medical Center from 1994 to 1999 were reviewed. Careful attention was paid to a clinical history of atopy. Atopic patients were selected, because these patients have been shown to have a "T(H)2 immune bias." The corneal graft rejection rate in these patients and the number of repeat corneal transplants performed was determined. The experimental group consisted of patients with a clinical history of atopy and keratoconus who had at least one repeat penetrating keratoplasty for an immunologically rejected corneal transplant. Any patient with evidence of primary allograft failure was excluded from this study. Tissue specimens from these patients were embedded in paraffin, serially sectioned, stained with Giemsa stains, and examined histologically. The control group consisted of patients without a clinical history of allergy (and therefore no T(H)2 immune bias) who underwent corneal transplantation for Fuch corneal endothelial dystrophy, or aphakic/pseudophakic bullous keratopathy. Failed grafts from these control patients were also paraffin embedded, serially sectioned, stained, and examined histologically. The human experimental and control corneal specimens were compared with data obtained in a murine model of T(H)2-mediated corneal allograft rejection. Briefly, full-thickness penetrating C57BL/6ByJ corneal allografts were transplanted onto Balb/cByJ and Balb/c-IFN-gamma(tm1Ts) (Balb/c-IFN-gamma knockout) mice. Additionally, full-thickness Balb/cByJ corneal allografts were transplanted onto C57BL/6ByJ and C57BL/6ByJ-IFN-gamma(tm1Ts) mice. Corneal allograft rejection rates and mean rejection times were calculated and compared between wild-type and interferon gamma (IFN-gamma) knockout hosts. The rejected allografts were examined histologically by the same methods used in the human tissue. RESULTS: There were 84 penetrating keratoplasties performed from 1994 to 1999 for keratoconus. Seven of these 84 patients rejected their corneal grafts. Of the 7 patients who rejected their corneal allografts, 4 had repeat penetrating keratoplasty. Of these 4 repeat corneal allografts, 3 showed eosinophilia when compared with rejected grafts in control patients. Atopic keratoconus patients had a mixed inflammatory cellular infiltrate in the rejected corneal tissue specimen with a significantly greater density of eosinophils (P =.001) compared with patients who did not have a pre-existing T(H)2 bias. The inflammatory infiltrate in these patients without a T(H)2 immune bias was mononuclear. In the murine model, corneal allograft rejection did occur in the absence of IFN-gamma, a critical T(H)1 cytokine in both fully allogeneic donor-host combinations. Histologically, rejection in these ("T(H)2 mice") was characterized by a predominant eosinophilic infiltrate in the rejected graft bed when compared with wild-type animals ("T(H)1 mice") that had a predominantly mononuclear infiltrate in the rejected corneal graft bed. CONCLUSIONS: Preliminary findings show that corneal allograft rejection in patients with a pre-existing T(H)2 phenotype is similar to what is seen in the murine model of T(H)2-mediated corneal allograft rejection. Based on this small sample, it appears that eosinophils may play a role in corneal allograft rejection in this group of patients. However, further study is necessary to determine the importance of these cells in allograft rejection.     

Confocal microscopy in the iridocorneal endothelial syndrome

AIMS: To report the appearances of iridocorneal endothelial (ICE) syndrome from real time, white light confocal microscopy. METHODS: Three consecutive patients, each with ICE syndrome, were examined prospectively. Corneal specular and confocal microscopic examinations were performed in all three patients. In the first patient, a penetrating keratoplasty was performed and the cornea was examined by light and scanning electron microscopy. No surgery was performed in the remaining two patients. RESULTS: In the first patient corneal oedema prevented endothelial specular microscopy. Confocal microscopy performed before penetrating keratoplasty successfully revealed abnormal epithelial-like endothelial cells. Histological examinations of the cornea following penetrating keratoplasty revealed the presence of multilayered endothelial cells with epithelial features (microvilli). In the remaining two patients, specular microscopy showed the presence of ICE cells with typical dark/light reversal. Confocal microscopy demonstrated groups of endothelial cells with epitheloid appearances. In all three patients, the contralateral endothelial appearance was normal by specular and confocal microscopy, except for moderate endothelial polymegathism in one patient. Epithelial-like endothelial cells were characterised by prominent nuclei on confocal microscopy. CONCLUSIONS: The application of confocal microscopy indicates that the ICE syndrome is characterised by epitheloid changes in the endothelium. Confocal microscopy may be used to diagnose the ICE syndrome by demonstrating epithelial-like endothelial cells with hyperreflective nuclei. This technique is especially of value in cases of corneal oedema, since specular microscopy may fail to image the endothelium in such cases.     

Conservative treatment of keratoconus by riboflavin-uva-induced cross-linking of corneal collagen: qualitative investigation

PURPOSE: To assess corneal tissue modifications after riboflavin-UVA-induced cross-linking of corneal collagen in patients with progressive keratoconus as well as regeneration of epithelium and subepithelial nerve plexus by in vivo HRT II system confocal microscopy in humans. METHODS: Ten patients with progressive keratoconus were treated by riboflavin-UVA-induced cross-linking of corneal collagen, involving assessment of ultrastructural modifications of the corneal epithelium and subepithelial nerve plexus by HRT II system confocal microscopy. Treatment included instillation of 0.1% riboflavin-20% dextrane solution 5 minutes before UVA irradiation and every 5 minutes for a total of 30 minutes. Radiant energy was 3 mW/cm 2 or 5.4 Joule/cm 2 and the source was dual UVA (370 nm) light-emitting LED. The protocol included the operation followed by antibiotic medication and eye dressing with a soft therapeutic contact lens. Changes in epithelium and subepithelial and stromal nerve plexus were assessed by HRT II system confocal microscopy in vivo. RESULTS: After 5 days of soft contact lens wearing, corneal epithelium has a regular morphology and density. Disappearance of subepithelial stromal nerve fibers was observed in the central irradiated area where, 1 month after the operation, initial reinnervation was microscopically observed. No changes in nerve fibers were observed in the peripheral untreated with a clear lateral transition between the two areas. Six months after the operation, the anterior subepithelial stroma was recolonized by nerve fibers with restoration of corneal sensitivity. CONCLUSIONS: HRT II system confocal microscopy confirms corneal epithelium restore and re-innervation after riboflavin-UVA-induced collagen cross-linking directly in vivo in humans.     

In vivo laser confocal microscopy after descemet stripping with automated endothelial keratoplasty

PURPOSE: To investigate in vivo corneal changes in patients with bullous keratopathies before and after Descemet stripping with automated endothelial keratoplasty (DSAEK) using laser confocal microscopy. DESIGN: Single-center, prospective, comparative clinical study. METHODS: Seven patients (two men, five women; mean age, 68.9 years; range, 59 to 78) with bullous keratopathies who underwent DSAEK enrolled in this study. Laser confocal microscopy was performed before and one, three, and six months after DSAEK. Selected images were evaluated qualitatively and quantitatively for degree of haze and density of deposits. RESULTS: Preoperatively, corneal epithelial edema, subepithelial haze, keratocytes in a honeycomb pattern, and tiny needle-shaped materials in the stroma were observed in all patients. After DSAEK, subepithelial haze, donor-recipient interface haze, and interface particles were observed in all five measurable cases; postoperative haze and particles decreased statistically significantly (P < .05) over follow-up. CONCLUSIONS: In vivo laser confocal microscopy is capable of identifying subclinical corneal abnormality after DSAEK with high resolution. Further studies in a large number of patients and long-term follow-up after DSAEK using this device are needed to fully understand long-term corneal stromal changes after DSAEK and whether the preexisting corneal stromal pathologies are reversible.     

Clinical course of epidemic keratoconjunctivitis: evaluation by in vivo confocal microscopy

PURPOSE: To describe, by in vivo confocal microscopy, the structural changes occurring during the course of adenovirus epidemic keratoconjunctivitis (EKC), from the onset of the disease up to 24 weeks of follow-up. METHODS: Eight patients (age, 8-57 years) with clinical evidence of EKC were examined and photographed in vivo with a Heidelberg Retina Tomograph II, Rostock Cornea Module. RESULTS: At 1 week, confocal microscopy revealed clusters of hyperreflective cells in the basal epithelial cell layer. In these sites, we observed subepithelial accumulations of dendritic cells, located mainly at the level of the Bowman layer. Underneath in the anterior stroma, we detected clusters of highly reflective, irregularly shaped cells. At 2 weeks, all patients presented follicular conjunctivitis, focal keratitis, and subepithelial infiltrates. At this point, confocal microscopy revealed persistent clusters of hyperreflective basal epithelial cells intermingled with roundish cells that probably represent leukocytes. Underneath, dendritic cells had formed an intricate network and, in the anterior stroma, we detected a hyperreflective cellular plaque that corresponded to the subepithelial infiltrate. At 24 weeks after onset of the symptoms, density and dimension of dendritic cell clusters were decreased, but we now detected stromal hyperreflectivity in the midstroma. CONCLUSIONS: In vivo confocal microscopic examination of subepithelial infiltrates appearing during EKC suggests that the innate immune system, as represented by the dendritic cells, is highly active early on. Nonetheless, the inflammatory component in both epithelium and stroma is massive and, in deeper stromal layers, long standing.     

A Case of Bilateral Descemet's Membrane and Subepithelial Opacity: In vivo Laser Confocal Microscopic Study

Purpose

To report the in vivo laser confocal microscopy findings from a patient with Descemet''s membrane and subepithelial opacity OU.

Case Report

A healthy 41-year-old male with Descemet''s membrane and subepithelial opacity OU was studied. Routine ophthalmic examination, standard slit-lamp biomicroscopy, and in vivo laser confocal microscopic analysis of the entire corneal layer were performed. Slit-lamp biomicroscopy revealed subepithelial opacity in the mid-peripheral to peripheral cornea and numerous opacities located at the level of Descemet''s membrane. It was difficult to distinguish the precise histological location of the opacity. In vivo laser confocal microscopy showed numerous hyperreflective particles in the subepithelium to superficial stroma and hyperreflectivity of Descemet''s membrane. No abnormalities could be detected in the epithelial cell layer, midstromal layer, deep stromal layer, or endothelial cell layer.

Conclusion

Although the origin of the corneal opacities was unclear, in vivo laser confocal microscopy was useful for observing microstructural abnormalities in a case of Descemet''s membrane and subepithelial opacity.Key words: Descemet''s membrane opacity, Subepithelial opacity, Confocal microscopy     

Corneal allograft rejection following immunization

Five patients developed corneal allograft rejection after immunization. One patient, a 33-year-old woman, received a tetanus toxoid booster nine months after a corneal transplant for keratoconus. Within four days she developed a graft rejection that required a penetrating keratoplasty two years later. Six months later, after hepatitis B immunization, the patient reported decreased vision and the graft was cloudy, but visual acuity was 20/20. The other four patients developed graft rejection after influenza immunization. Two of these four graft rejection episodes were successfully treated with high-dose corticosteroid therapy; all episodes occurred within several weeks of influenza immunization. Patients should be prudently counseled regarding the possible risks of immunization to corneal allograft survival.     

Factors influencing the decline in endothelial cell density after corneal allograft rejection

PURPOSE: Corneal allograft rejection is one of the major causes of transplant failure. The purpose of the current study was to examine the decline in endothelial cell density (ECD) in patients experiencing allograft rejection, by comparing this decline with the normal evolution in patients who undergo penetrating keratoplasty (PKP) and to identify possible factors predictive of this endothelial cell loss after corneal allograft rejection. METHODS: In a case-control study of 45 corneas that underwent corneal allograft rejection, specular microscopy photographs taken within the shortest time preceding the onset of rejection and after the resolution of the rejection were analyzed. RESULTS: The observed percentage loss of ECD in 21 (47%) corneas was not significantly greater than expected. A second group of 13 (29%) corneas showed a decline in ECD that was significantly greater than expected. Finally there were 11 corneas (24%) in which endothelial cells were no longer observable. The only two risk factors that reached statistical significance after multiple logistic regression analysis were a delay in diagnosis (a delay of >1 day yielded an odds ratio of 10.40; P=0.02) and a recipient age of more than 60 years (odds ratio, 6.95; P=0.04). CONCLUSIONS: Corneal allograft rejection does not necessarily cause a higher than expected endothelial cell loss; almost half of the patients in this study showed a decline in ECD that is comparable to the decline in patients who undergo PKP and have an uneventful follow-up. The most important variable influencing the extent of endothelial cells loss is a delay in diagnosis and treatment.     

Diagnosis of epithelial ingrowth after penetrating keratoplasty with confocal microscopy

PURPOSE: To report confocal microscopy use in the clinical diagnosis of epithelial ingrowth after penetrating keratoplasty (PKP). METHODS: A 36-year-old female patient with keratoconus developed a well-delimited posterior hazy membrane covering the inferior two thirds of the cornea 3 months after an uneventful PKP. A posterior corneal line was present resembling an endothelial graft rejection line, but with no keratic precipitates or corneal edema. Ocular hypertension was not observed. Confocal microscopy was performed to elucidate the diagnosis. RESULTS: Confocal microscopy showed epithelium and stroma with normal findings. Two distinct cellular types were presented at the endothelium layer. Enlarged endothelial cells were observed in the superior part of the cornea up to the leading edge of the hazy membrane. In the middle and inferior part of the graft, the cells were larger, with polygonal shape and easily recognizable hyperreflective nuclei, suggestive of epithelial cells. With these confocal microscopy findings, the patient was promptly submitted to another PKP. Histologic analysis confirmed the diagnosis of epithelial ingrowth. CONCLUSION: Confocal microscopy imaging technique seems to be a useful tool in the early diagnosis of epithelial ingrowth after PKP.     

Diffuse lamellar keratitis associated with recurrent corneal erosions after laser in situ keratomileusis

PURPOSE: Diffuse lamellar keratitis (DLK) is marked by the presence of diffuse or multifocal infiltrates confined to the laser in situ keratomileusis (LASIK) interface. These infiltrates are culture-negative, and the etiology is thought to be noninfectious. Most cases of DLK occur within the first week or two following surgery. METHODS: We describe one case of diffuse lamellar keratitis that occurred 3 months after LASIK. The patient developed a spontaneous corneal erosion in one eye. Over the next 2 days while the erosion was being treated, there was rapid development of DLK. Slit-lamp biomicroscopy and in vivo scanning slit confocal microscopy were performed. The patient was treated with intensive topical corticosteroids. RESULTS: Scanning slit confocal microscopy revealed numerous, highly-reflective round bodies consistent with a polymorphonuclear infiltrate located at the flap interface. Treatment with topical 1.0% prednisolone acetate was instituted, with rapid improvement in patient symptoms, visual acuity, and slit-lamp biomicroscopy. CONCLUSIONS: Diffuse lamellar keratitis may occur months after LASIK as a result of a spontaneous recurrent corneal epithelial erosion.     

In vivo confocal microscopy in the patients with cornea farinata

PURPOSE: To report in vivo corneal confocal microscopic findings of patients with cornea farinata. PATIENTS AND METHODS: Two unrelated patients, a 47-year-old man and a 77-year-old woman, with cornea farinata were studied. Examination with a confocal microscope was performed in addition to routine slit-lamp biomicroscopy. RESULTS: In both cases, slit-lamp biomicroscopy showed numerous small, faint opacities in the deep stroma in both eyes. Using confocal microscopy, highly reflective small particles were observed in the cytoplasm of keratocytes in the deep stroma adjacent to the corneal endothelial layer. No abnormalities could be detected in the epithelial layer, in the mid-stromal layer, at the level of Descemet's membrane, and in the endothelial layer. CONCLUSIONS: In vivo corneal confocal microscopy is useful for observing stromal abnormalities in cornea farinata. Further investigation of posterior stromal opacities using confocal microscopy may be useful to understand and differentiate various corneal conditions involving primarily deep stromal layers.     

Subepithelial amyloid deposits in congenital hereditary endothelial dystrophy: a histopathologic study of five cases

PURPOSE: To report the clinical, histologic, ultrastructural, and immunohistochemical features of congenital hereditary endothelial dystrophy (CHED) associated with subepithelial amyloid deposits. METHODS: The clinical features of seven patients and histologic characteristics of eight corneal buttons were evaluated. The corneal specimens included five cases with histologic features of CHED associated with subepithelial amyloid. The remaining three corneal buttons of CHED without amyloid were obtained from the fellow eye of an affected patient and from siblings of two affected patients. Light microscopic studies were performed on sections stained with hematoxylin and eosin, periodic acid Schiff stain, and Congo red stain with and without permanganate bleach. Immunohistochemistry with an antibody to the amyloid AA protein and lambda and kappa light chains was done on all specimens. Electron microscopy was performed on three corneal specimens. The cases were followed for 1-9 years. RESULTS: The notable clinical findings included decreased vision, history of parental consanguinity (4/7 cases), and affected siblings (5/7 cases). Examination revealed nystagmus (5/7 cases) and bilateral ground-glass corneas in all patients. In addition, central subepithelial whitish opacities were noted in patients with CHED and amyloid. Three patients had associated congenital glaucoma. The patients underwent penetrating keratoplasty at a mean age of 10 years. Histologically, five corneal buttons of CHED revealed varying degrees of subepithelial amyloid deposits associated with a subepithelial fibrous pannus. Immunohistochemically, the deposits were nonreactive to anti-amyloid A antibody but were immunoreactive with an antibody to lambda light chains in two cases. Electron microscopy confirmed the presence of subepithelial amyloid. Thickening of Descemet's membrane and attenuation of corneal endothelial cells, noted in all cases, was consistent with features of CHED. The corneal buttons from the fellow eye and the siblings showed histologic features of CHED, with a subepithelial fibrous pannus without amyloid deposits. Spheroidal degeneration was noted in two corneal specimens. To date, no recurrence of the amyloid deposits has been seen in the grafts. CONCLUSIONS: This study demonstrates that subepithelial amyloidosis may be rarely associated with a recessive form of congenital hereditary endothelial dystrophy. The clinical, histologic, and immunohistochemical features suggest a secondary form of amyloidosis.     

Keratoconus associated with corneal macular dystrophy: in vivo confocal microscopic evaluation

PURPOSE: The authors present a case, studied through in vivo confocal microscopy, of concomitant keratoconus and macular corneal dystrophy (MCD). METHODS: A 29-year-old man underwent a penetrating keratoplasty in the right eye in May 2005. Confocal microscopy was performed to examine the cornea of the right eye. RESULTS: A diagnosis of concomitant keratoconus and MCD was suspected, due to the simultaneous findings of corneal ectasia and stromal opacities. CONCLUSIONS: In this case, using in vivo confocal microscopy, morphologic changes were detected in many corneal layers and compared with the histopathologic findings. The morphologic alterations were found mainly in the area of the cornea apex.     

Treatment of corneal transplant rejection in humans with anti-interferon-gamma antibodies

PURPOSE: To determine efficacy of anti-human interferon-gamma F(ab')2 (Fabs) in treating corneal transplant rejection after penetrating keratoplasty. DESIGN: Interventional case series. METHODS: Anti-interferon-gamma Fabs derived from goat antihuman interferon-gamma antibodies were used for instillations in 13 patients (13 eyes) who experienced corneal transplant rejection after penetrating keratoplasty. Fabs were administered in one or three treatment course(s) as eyedrops given three times daily for 7 to 10 days. RESULTS: In 10 patients, 2 to 3 days after start of one treatment course, transplant transparency improved, and edema decreased. At the end of week 1, the transplant became almost fully transparent, and eye inflammation disappeared. Visual acuity increased from 0.2 to 0.3. In the other three patients, three treatment courses were needed for comparable improvement. Improvement was maintained through follow-up-an average of 7 months. CONCLUSION: Antihuman interferon-gamma Fabs may be safe and effective in halting corneal transplant rejection after penetrating keratoplasty.